The document provides an overview of medical coding systems used in the United States, including the Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS). It describes the different levels of service codes, types of CPT codes, format and organization of the CPT manual, and use of modifiers. It also summarizes HCPCS and its use of national codes to cover a wide variety of medical services, providers, and supplies.

1. CHAPTER 13 INTRODUCTION TO THE CPT AND LEVEL II NATIONAL CODES (HCPCS)

2. MEDICAL CODING Transforms services/procedures/ supplies/drugs into __________ codes Transforms diagnosis and procedures into ________ codes CPT/HCPCS ICD-9-CM

3. Levels of Service Codes Level I CPT—(Category 1: 99201-99607, Category III: 0017T-0259T) Level II HCPCS, National Codes—(A0021-V5364) Level III Local Codes—phased out due to HIPAA

4. Diagnosis Codes ICD-9-CM, Volumes 1 & 2 International Classification of Diseases , 9th Ed., Clinical Modification

5. ICD-9-CM Classification ______ Explains why service was provided Changes diagnoses into _____ Diabetes becomes ___ .XX (highest level of specificity) system 250 codes

6. Why Codes? Computers understand ________ Specific descriptions attached to each code numbers

7. CPT Developed by the AMA in ____ ____ -digit codes Updated in _________ for use January 1 Five 1966 November

8. Examples of Types of CPT Codes Medical Surgical Diagnostic services Anesthesia, etc. Category II and Category III codes—alpha numeric Category II = ___________ measuring Category III = emerging __________ performance technology

9. CPT Codes Allow For Communication that is both _______ and _______ A mechanism to report a service not described by a specific CPT or Level II code effective efficient

10. Consider Renal endoscopy through nephrostomy or pyelotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with endopyelotomy (includes cystoscopy, ureteroscopy, dilation of ureter and ureteral pelvic junction, and insertion of endopyelotomy stent) OR 50575

11. Codes Are Used to tell third-party payers about ________ /procedures provided Often used as basis of _______ services payment

12. Incorrect Coding Results in providers being paid _____________ Either over or underpayment Decreases cash flow Liability risk inappropriately

13. Codes Are Used By Clinics Hospitals Rehabilitation units Ambulance services Long-term care Wherever __________ services are provided health care

14. Outpatient Services for Physicians Reported on insurance form _________ = universal form CMS-1500

15. CMS-1500 Figure: 13.1

16. CPT Format Symbols in CPT Used to convey __________ ________ , moderate (conscious) sedation included (full list in Appendix G, CPT) Example 45391, Colonoscopy with endoscopic ultrasound examination ____________ , pending FDA approval (Appendix K, CPT) Example 90650, Human Papilloma virus (HPV) vaccine, types 16, 18, bivalent, 3 dose schedule, for intramuscular use information Bullseye Lightning bolt

17. • Bullet = ____ Code Figure: 13.2 Circle ( ○ ) = Reinstated or recycled code New Figure: 13.6

18. ▲ Triangle = _______ Code Figure: 13.3 Revised

19. ►◄ Right and Left ________ = Beginning and Ending of Text Change Figure: 13.4 Triangles

20. _____ = Add-On Code Figure: 13.5 + Plus

21. Add-On Code (…Cont ’d) Can only be used with another specific code Never used _____ No reduction for multiple services Full list in Appendix _ of CPT alone D

22. =Circle With Line, CPT Appendix E contains a listing of - 51 exempt codes Services typically exempt from multiple procedure reductions -51 Cannot Be Used With these Codes Figure: 13.7

23. Appendices of CPT Appendix A : ________ Appendix B : Additions, ________ , Revisions Appendix C : Clinical Examples, ___ Codes Appendix D : _______ Codes Appendix E : ___ Exempt Codes Appendix F : ___ Exempt Codes Appendix G : Include Moderate ( _________ ) Sedation Modifiers Deletions E/M Add-On -51 -63 Conscious (Cont ’d…)

24. Appendices of CPT (…Cont ’d) Appendix H : Performance Measures, Category __ Codes, on website Appendix I : Genetic Testing ________ Appendix J : Electrodiagnostic Medicine Listing of _______ , _____ , and Mixed Nerves Appendix K : Product Pending ____ Approval Appendix L : ________ Families Appendix M : Crosswalk to _______ CPT Codes Appendix N : Summary of Resequenced CPT Codes II Modifiers Sensory Motor FDA Vascular Deleted

25. ___ CPT Sections (like chapters) Evaluation & Management (E/M) Anesthesia Surgery Radiology Pathology & Laboratory Medicine Category II Codes Category III Codes Appendices A-M Index Six

26. Categorized By Sections Subsections Subheadings Categories

27. Categorized By (…Cont ’d) ________ Knee or Shoulder _________ Incision or Excision _________ Fracture or Dislocation __________ Cast or Strap ________________ Anterior Cranial Fossa or Middle Cranial Fossa Anatomy Procedure Condition Description Surgical Approach

28. Categorized By, Example Figure: 13.9 (…Cont ’d)

29. Guidelines Section-specific information begins each section Figure: 13.10

30. Notes Must-reading located throughout the CPT Figure: 13.12

31. Two Types of Codes Stand-alone: ___ description Indented: Dependent on _________ __________ Verbiage before the semicolon applies to all indented codes that follow Full preceding stand-alone

32. Types of Codes, Example Figure: 13.14

33. Semicolon Indicates full description in ______________ You must return to the stand-alone for full description preceding code

34. Modifiers Add Information CPT Modifier Two digits 62 Two surgeons performed a surgical procedure Each surgeon applies his/her individual skill Each surgeon bills the procedure with modifier -62

35. Level II HCPCS Modifiers “ -AS” Physician’s Assistant “ -F1” Left hand, second digit __ modifiers used on CPT or HCPCS All

36. Example of Modifier 43820 Gastrojejunostomy -62 two surgeons -43820-62 two surgeons performed a gastrojejunostomy -62 modifier may be allowed based on payor Example: Medicare requires documentation of medical necessity

37. Modifier on the CMS-1500 Modifiers are placed in 24D on CMS-1500

38. Unlisted Services Codes ending in ____ = “no specific Category I or III code” Used if ___________________ ____________ must accompany submission “ 99” no more specific code Special report

39. Special or Written Report Indicates: Nature Extent Need Time Effort __________ Used Photos and medical journal articles if relevant Equipment

40. Category I Codes Category _ codes (00100–99607) Approved by AMA and Food and Drug Administration Proven clinical effectiveness (efficacy) I

41. Category II Codes— Supplemental Tracking Codes Used for ___________ measurements Codes collect data concerning quality of care and test(s) required ____________ and end in the letter “F” (1006F) Location AMA Website performance Alphanumeric

42. Category III Codes— New Technology Temporary codes—up to _ years Identify emerging technology, services, and procedures Located after ________ section Alphanumeric (0016T) May or may not receive future ________ I code status 5 Medicine Category

43. Category III Codes Category __ codes have not been approved and have no proven clinical effectiveness Usage order Use ___________ code instead of unlisted code Use unlisted code if no Category III code III Category III

44. The Index! Used to locate service/procedure terms and codes Speeds up code location Like a dictionary First entries and last entries

45. CPT Index Figure: 13.18

46. Presentation of Codes in Index Single code: 38115 Multiple codes: 26645, 26650 - Note ______ Range of codes: 22305-22325 - Note ______ comma hyphen

47. Location Methods With Examples ________________ : repair, excision ____________ : median nerve, elbow __________________ : cleft lip, clot ________ : toe and interphalangeal joint _______ : Jones procedure, Heller operation ___________ : ECG, PEEP (Pressure Breathing, Positive) Service/procedure Anatomic site Condition or disease Synonym Eponym Abbreviation

48. Always Reference index Locate code in ___________ of CPT Read the entire __________ and any _____ main portion description notes

49. “ See” in Index Cross-reference terms “ Look here for code” Index: Stem, Brain: See Brainstem

50. HCPCS Healthcare Common Procedure Coding System Developed by Centers for Medicare and Medicaid Services ( ____ ) Formerly _____ HCPCS developed, ____ CPT did not contain all codes necessary for Medicare services reporting CMS HCFA 1983

51. Levels of Codes Level I: ___ Level II: _______ , also known as national codes Level III: Local codes ( __________ ) due to HIPAA CPT HCPCS phased out

52. Level III, Local Codes Developed by Medicare carriers for use at local level Varied by locale Discontinued December 31, 2003 Some codes incorporated into HCPCS Level I and II

53. Level II: _______ Codes Codes for wide variety of providers Physicians Dentists Orthodontists Temporary codes for Medicare National (Cont ’d…)

54. Level II: National Codes (…Cont ’d) Codes for wide variety services Specific drugs ________________________ (DME) Ambulance services Durable medical equipment

55. HCPCS Gains Popularity Many payers require Each year increased number of HCPCS codes J0585—Botox, per unit

56. Format Begins with ____ , followed by four _____ Example: E0618, apnea monitor Each letter represents group of codes Example: “ _ ” codes used to report drugs and dosage letter digits J

57. Temporary Codes Certain letters ( _ , K, _ , S, H, T) indicate temporary codes Example: K0006 heavy duty wheelchair Code books published every ______ But codes added, deleted, and revised throughout the year Notified through carrier bulletins G Q January

58. Coverage Just because item/service has HCPCS code does NOT mean service covered Example: V5130, _______ __________ Not covered under Medicare From Cummings CW, Flint PW, Harker LA, Haughey BH, Richardson MA, Robbins KT, Schuller DE, Thomas JR, editors: Cummings Otolaryngology-Head & Neck Surgery, ed 4, Philadelphia, 2005, Mosby. binaural hearing aid

59. Where HCPCS Are Used _________ settings Including outpatient departments in hospital Level I and II used to report outpatient services to certain payers Outpatient

60. HCPCS Index Directs to specific codes Do not code directly from index Reference main portion text before assigning code See Figure 13 – 22 in textbook (Cont ’d…)

61. HCPCS Index Alphabetical order (Cont ’d…) (…Cont ’d) Figure: 13.22 Modified from Buck CJ: 2011 HCPCS Level II Professional Edition, St. Louis, 2011, Saunders.

62. HCPCS Index Main text display (…Cont ’d) Figure: 13.27 Modified from Buck CJ: 2011 HCPCS Level II Professional Edition, St. Louis, 2011, Saunders.

63. HCPCS Modifiers ___ and ______ modifiers used with both HCPCS and CPT codes Figure: 13.25 CPT HCPCS Modified from Buck CJ: 2011 HCPCS Level II Professional Edition, St. Louis, 2011, Saunders.

64. Anatomical Modifiers F1 Left hand, second digit __ Left hand, third digit F3 Left hand, fourth digit F4 Left hand, fifth digit FA Left hand, thumb __ Right hand, thumb F6 Right hand, second digit F7 Right hand, third digit __ Right hand, fourth digit F9 Right hand, fifth digit F2 F5 F8

65. Often Used HCPCS Modifiers __ Left __ Right Example: Right kidney biopsy, 50200-RT Left kidney biopsy, 50200-LT LT RT

66. Ambulance Modifiers Origin and destination used in combination: First letter: _____ Second letter: __________ Example: R = Residence H = Hospital RH: origin (first letter) residence and destination (second letter) hospital Origin Destination

67. Table of Drugs Listed by generic name Modified from Buck CJ: 2011 HCPCS Level II Professional Edition, St. Louis, 2011, Saunders. Figure: 13.26

68. Durable Medical Equipment DME Used with chronic disabling condition Medicare and Medicaid pay for some DME items Physician must attest to need using __________________ Necessity Certificate of Medical

69. Home Oxygen Therapy Medicare may also pay for oxygen with certain medical conditions Physician must complete form (CMS- ___ ) attesting to medical necessity 484

70. Conclusion CHAPTER 13 INTRODUCTION TO THE CPT AND LEVEL II NATIONAL CODES (HCPCS)